University of Arkansas for Medical Sciences

Request for Medical or Religious Exemption from Influenza Vaccination

Employee Name______Date of Birth______

SAP#______

The University of Arkansas for Medical Sciences is mandating influenza vaccination for all of its employees, similar to other required vaccinations such as MMR. Each request for exemption, regardless of the reason, will be evaluated individually by Student Employee Health Services and/ or the Office of Human Resources.

Medical exemption ______

I understand that by requesting an exemption due to medical contraindications I will be required to provide documentation from my primary care physician. I also understand that the medical exemption must be based on standard criteria for medical exemptions recommended by the Centers for Disease Control and Prevention or Advisory Committees on Immunization Practices.

Religious exemption ______

I understand that by requesting an exemption due to religious beliefs I will be required to provide documentation such as a letter from my religious leader/pastor verifying my membership affiliation and the reasons and/or religious practices that do not support immunization.

I understand that I will be provided 10 business days to obtain the supporting documentation for either the medical or religious exemption.

I understand that I will receive written notification regarding status of exemption request within five (5) business days after the required documentation has been provided UAMS Student Employee Health Services.

I understand that if my exemption request is approved I will be recognized as compliant with the mandatory influenza vaccination requirement. Further, I understand that my protected medical and religious information will be maintained in my confidential Employee File in Human Resources. This information will not be provided to anyone outside of UAMS Human Resources.

I understand that I will be expected to follow infection control guidelines and care for patients admitted/seen with influenza-like illness as my job duties require. I will follow transmission-based precautions for patients with symptoms of influenza-like illness. I understand that if I develop an influenza-like illness, I must report to Student Employee Health Services for potential work exclusion until resolution of symptoms.

For any questions concerning these exemptions please contact, Student Employee Health Services at 686-6565 or the Office of Human Resources at 686-5650.

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Employee SignatureDate

UAMS Form for Medical Exemption from Influenza Vaccination

Employee Name______Employee Date of Birth______

(Print) (Print)

Dear Physician:

The University of Arkansas for Medical Sciences is mandating influenza vaccinations for all of its employees, similar to other required vaccinations such as MMR. Your patient has requested a medical exemption from this vaccination requirement. A medical exemption from influenza vaccination is allowed for recognized contraindications only and any medical exemption request will be reviewed individually with medical information.

Please complete the form below to request a medical exemption for your patient. Should you have any questions, please call UAMS Student Employee Health Services at 501-686-6565. We may contact your office to confirm and discuss reasons for exemption.

UAMS Student and Employee Health provides the FLUBLOK for those employees with an allergy to eggs and this is no longer a valid exemption to the flu vaccine.

Employees with a severe allergic reaction to eggs should notify Student and Employee Health in order to receive the FLUBLOK.

  • Defined as developing hives, swelling of the lips or tongue, difficulty breathing
  • Does not generally include gastro-intestinal systems
  • The amount of egg protein in influenza vaccines is extremely small. People who can tolerate eating foods prepared with eggs, such as baked goods, can generally tolerate the influenza vaccine.

My patient should not be vaccinated against influenza for the following reason:

History of previous severe allergic reaction to the influenza vaccine or component of the vaccine

  • Defined as developing hives, swelling of the lips or tongue, difficulty breathing
  • Does not include sore arm, local reaction, or subsequent upper respiratory tract infection.

History of Guillan-Barre syndrome within 6 weeks of receiving a previous vaccine

  • People with this history can choose to receive the vaccine

Other, please describe below(AS PER THE CDC NOT TO INCLUDE THOSE INDIVIDUALS WITH MILD ALLERGY TO EGGS, IMMUNOSUPPRESSED , CHRONIC MEDICAL CONDITIONS OR PREGNANCY)

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I certify that my patient has the above contraindication, and request medical exemption from influenza vaccination.

Physician Signature______Date______

(Signature stamps not acceptable)

Physician Printed Name______Physician phone#______

Fax Completed Form to: UAMS Employee Health Services 501-296-1230 OR E-MAIL